197609117-3-30-2021-29-AS-JAPL-BZNU6S-20210401151847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609117
Report Date: 03/30/2021
Date Signed: 03/30/2021 01:04:10 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20200813122045

FACILITY NAME:	SILVERADO SENIOR LIVING - CALABASAS		FACILITY NUMBER:	197609117
ADMINISTRATOR:	GIUNTO, TAYLOR		FACILITY TYPE:	740
ADDRESS:	25100 CALABASAS RD		TELEPHONE:	(818) 222-1000
CITY:	CALABASAS	STATE: CA	ZIP CODE:	91302
CAPACITY:	110	CENSUS: 55	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Taylor Giunto		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Due to lack of supervision, resident sustained injuries while in care
Facility failed to seek timely medical attention
Facility did not meet resident's incontinent needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith conducted a complaint inspection at 11:30am to deliver the findings of the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s investigation was conducted via FaceTime with Executive Director Taylor Giunto.

On 8/13/2020, the Department received a complaint stating that while residing at the facility, Resident #1 (R1) experienced multiple unexplained injuries and bruises, did not receive timely medical attention when R1 complained of pain, and it was alleged that the facility failed to care for their incontinent needs. Community Care Licensing Division’s Investigations Branch (IB) Investigator Jose Santana was assigned to the case. On 8/14/2020, the LPA interviewed the Executive Director and requested documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200813122045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 03/30/2021

NARRATIVE

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Investigator Santana reviewed facility and medical documents on 8/25/2020 and 9/22/2020; interviewed R1 on 8/20/2020; interviewed a collateral agency representative on 8/24/2020; interviewed a family member on 8/24/2020, 9/2/2020, 9/15/2020 and 10/15/2020; interviewed R1’s primary care physician on 8/25/2020 and 9/11/2020; and, interviewed R1’s psychiatrist on 10/2/2020. Investigator Santana also conducted the following staff interviews: three interviews on 9/17/2020, one interview on 9/23/2020; one interviews on 10/22/2020; one interview on 11/09/2020; seven interviews on 11/12/2020; five interviews on 11/13/2020; one interview on 11/18/2020; five interviews on 11/19/2020; one interview on 11/20/2020; one interview on 12/4/2020; one interview on 12/10/2020; one interview on 12/11/2020; and, one interview on 12/14/2020.

Regarding the allegation: Due to lack of supervision, resident sustained injuries while in care
It was alleged that R1 sustained multiple bruises and injuries due to lack of supervision. Injuries included, but were not limited to: discoloration on R1’s right wrist on 12/8/2019, scratches to R1’s hand on 12/17/2019, skin tear to the right elbow on 12/18/2019, swollen and bruised middle finger on the left hand on 12/21/2019, laceration of R1’s nose on 1/13/2020, and bruising to the right temple on 1/26/2020. There was a concern with the frequency of injuries and the unexplained origin of the bruising.

A review of Facility Progress Notes pertaining to R1 revealed that within a seven week span, the following incidents involved R1 displaying aggression either towards staff or residents:12/8/2019, 12/17/2019, 12/20/2019, 12/27/2019, 1/6/2020, 1/7/2020, 1/8/2020, 1/13/2020, 1/14/2020, 1/15/2020, 1/17/2020, 1/18/2020, 1/19/2020, 1/25/2020, and 1/26/2020. Interviews revealed that the multiple incidents appeared ‘above average’ and believed that the bruising and skin tears may have resulted from the above-mentioned incidents. However, interviews also revealed that R1 was often observed with bruises, cuts, and bleeding, but the origin of the injury was oftentimes unknown at the time of observation.

Interviews revealed that R1 was combative and aggressive towards residents and staff, yet appeared to work well with female staff. However, some staff, both female and male, disclosed that they feared working with R1 due to the heightened risk of injury and unpredictable behavior; and, some revealed that they would refuse to provide care and oversight for R1. Many described numerous occasions where R1 chased staff through facility halls, would throw things, and would become violent towards staff that attempted to assist R1 with activities of daily living. Staff shared that to address aggressive behavior, they would redirect or distract a resident, try to identify a different staff that the resident could get along with, or attempt to intervene at a later time. However, pertaining to R1, some staff admitted to not returning to provide care and assistance.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200813122045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 03/30/2021

NARRATIVE

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Staff identified that R1 was more triggered by male residents and staff. For example, a laceration on R1’s nose from 1/13/2020 came from an altercation with Resident #2 (R2), in which R1 punched R2, and R2 thereafter threw a glass cup in R1’s face. Interviews revealed that that there was a high probability for an altercation to occur if R1 and R2 were in the same vicinity as one another, yet there were not clear guidelines or instructions to keep the residents apart. Lastly, interviews revealed that staff had not received extensive training on managing aggressive behaviors and were simply told to inform facility Licensed Vocational Nurses (LVNs) about behavioral challenges. At that point, the LVNs were to document R1’s behavior and then confer with R1’s doctors to identify if medications needed to be adjusted. The IB Investigator was unable to identify a concrete plan to mitigate or circumvent R1’s aggression outside of adjusting medications.

A review of faxed medical orders and interviews demonstrated that the facility attempted to control R1’s behavior by managing and adjusting R1’s psychotropic medications as needed, yet interviews with medical professionals revealed that it yielded limited success, as R1’s aggression continued. Whereas it was communicated that R1’s dementia may have altered their behavior to the point of becoming increasingly aggressive, it was noted that the facility’s open layout could be problematic for aggressive residents as they can become more intrusive with one another. Although staff were aware of R1’s behavior, R1 had free reign to walk through the hallways with seemingly no additional oversight or supervision. In addition, multiple interviews stated that R1 was able to take butter knifes and utensils from dining and carry them in R1’s pocket, which would later have to be confiscated. Interviews revealed that in order to create a safer environment for residents with aggressive behavior, it would have taken additional staffing, additional oversight, or a protocol in which a resident would receive 1:1 care in order to decrease incidents. However, staff interviews confirmed that there was nothing substantial in place outside of managing medications.

Whereas the facility is not in the position to prevent all negative encounters, it was known that there was a high probability that R1 would continually engage in altercations with staff and residents that potentially could have resulted in injury. R1 continued to freely wander the hallways without constant supervision despite R1’s unpredictable aggressive behavior. R1 sustained multiple injuries in a short span of time, and the facility was unable to provide care plans that detailed how the facility was managing R1’s aggressive behavior outside of adjusting medications. Per the interviews, the medication adjustment did not always yield positive results. Based on the investigation, there is sufficient evidence to support the claim that R1 sustained multiple injuries due to lack of supervision. This allegation is deemed Substantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200813122045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 03/30/2021

NARRATIVE

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Regarding the allegation: Facility failed to seek timely medical attention
It was alleged that the facility failed to seek timely medical attention for R1 when R1 expressed and exhibited continued abdominal pain. On 02/02/2020, R1’s family observed that R1 was in pain. R1's family informed staff of R1’s pain and at the request of the family, the staff obtained an order from R1’s primary care physician for abdominal x-rays. The x-rays of R1's abdomen and bilateral ribs were completed on 02/03/2020 and showed no abnormalities. However, R1 continued to express abdominal pain and discomfort.

R1’s family allegedly asked staff if they would call an ambulance, but interviews revealed varied responses as to how staff responded to the family’s inquiry about sending R1 to the hospital via ambulance. Due to the response received from staff, it was concluded that the facility did not call 9-1-1 as a result of the continued abdominal pain. R1’s family transported R1 to the hospital in their private vehicle. A review of medical notes reveals that R1 was admitted to the hospital on 02/03/2020 at 4:46pm for unspecified abdominal pain, and R1 was found to have gallstones. It was noted that R1 would require very close outpatient follow-up.

Interviews with witnesses of the incident provided varied statements as to what transpired; however, interviews also claimed staff felt that R1’s grimacing and pain did not rise to the level of calling 9-1-1. It was also disclosed that R1's continued abdominal pain had not been brought to the attention to the facility LVNs. Yet additional caregiver interviews negate this claim, stating that they observed that R1 had experienced pain for several days prior to being hospitalized and noted that the concern had been elevated to the facility LVNs per protocol.

Based on the investigation, there is sufficient evidence to support the claim that the facility failed to seek timely medical attention for R1. Even though the x-ray displayed no abnormalities, the facility did not take further action to assess the cause of R1's continued pain. Whereas staff could not disclose additional detail as to why the facility did not call 9-1-1 at the request of the family, R1’s family took R1 to the hospital and after an ultrasound was completed, discovered that the source of R1’s pain was due to gallstones. This allegation is deemed Substantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200813122045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
	VISIT DATE: 03/30/2021

NARRATIVE

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Regarding the allegation: Facility did not meet resident's incontinent needs.
It was alleged that R1 was often left unchanged and soaked in urine for long periods of time. Staff interviews revealed that residents should be checked, changed, and/or refreshed at least every two hours. However, staff admitted that due to staffing shortages, residents were checked every 3-4 hours. In addition, staff admitted that R1 was extremely resistant and combative when caregivers tried to assist R1 with being changed. Also, staff admitted that they feared R1’s unpredictable aggression. As such, multiple staff admitted that there were many times where R1 was found soaked in urine for an undetermined amount of time. Whereas residents have the right to refuse care, some interviews revealed that if R1 had become combative during changing, they may inform the facility LVNs that R1 was resistant and not return to R1 to assist with changing R1.

Based on the investigation, there is sufficient evidence to support the claim that the facility did not meet R1’s incontinent needs. R1’s unpredictable behavior and resistance to receiving assistance for changing deterred staff from assisting R1. As a result, R1 was often not changed until a caregiver could gain R1’s compliance, and this meant that R1 would remain soiled for prolonged periods. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided via email for signature, along with appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20200813122045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/01/2021 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Submit a Plan of Action/Protocol, detailing how staff are trained to manage aggressive behaviors with residents diagnosed with dementia.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 sustained multiple injuries and bruises due to lack of care and supervision, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	2. Schedule an in-service training for caregivers and LVNs that specifically speaks to managing aggressive behaviors. Training needs to be completed in the next two weeks. Submit proof of completion to CCLD.
Request Denied Type A 04/01/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to Title 22 Regulations regarding emergency medical assistance.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as the facility failed to ensure that R1 received timely medical attention when R1 expressed pain, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Submit to CCLD by 4/1/2021

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20200813122045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVERADO SENIOR LIVING - CALABASAS	FACILITY NUMBER: 197609117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/01/2021 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	Managed Incontinence. The Licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Conduct an in-service with staff, pertaining to Regulation 87625. Schedule in-service in the next two days; submit dates to CCLD by 4/1/2021. Training must be completed in the next two weeks.
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above, as R1 remained soiled for prolonged periods for various reasons, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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